Digital Repository Doctoral Projects Spring 2021 Bedbugs: Increasing Awareness and Educating Providers on Best Practices Holly Marcusen Wright, DNP, APRN, FNP-C Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Wright, H. M. (2021). Bedbugs: Increasing Awareness and Educating Providers on Best Practices Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Bedbugs: Increasing Awareness and Educating Providers on Best Practices by Holly Marcusen Wright A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 26, 2021 Jessica Bartlett DNP, CNM, RN, IBCLC _____________________________ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE ________________________________ (Graduate Programs Director) Running head: BEDBUGS: INCREASING AWARENESS AND EDUCATING 1 Bedbugs: Increasing Awareness and Educating Providers on Best Practices Holly Wright DNP, APRN, FNP-C Annie Taylor Dee School of Nursing April 20, 2021 BEDBUGS: INCREASING AWARENESS AND EDUCATING 2 Acknowledgement Thank you to Dr Jessica Bartlett who shared her enthusiasm with me on my project, who guided me towards scholarly results and who never gave up on helping me accomplish my DNP goals. She spent much time editing, critiquing, and answering my relentless questions. To Ruth Brockman MBA, RN a local nurse leader who has cared for the underserved in Ogden for at least three decades, and who was instrumental in helping as my community project consultant. To all those who had the vision and drive to worked to create and develop the FNP and DNP programs here at Weber State University. Dr. Melissa Neville-Norton who inspired me to conduct undergraduate research in 2014 and to “never give up” during my FNP and DNP studies. To Dr. Deborah Judd for her kindness and guidance and who helped me along the way. Dr. Reynolds who shared ideas and enthusiasm and conversations with me on this DNP project before school even began. Dr Susan Thornock who helped me choose academia. To Marlene Summers who always supported and encouraged me. She also recruited me to the board of Sigma. Thank you to all my teachers who have been a part of this ADN, BSN, FNP and DNP journey and to all the faculty and staff of Weber State University’s Annie Taylor Dee School of Nursing who are too many to name but who are cherished for their kindness and help. And in memory of Karen Beaver BSN, RN whose simple act of kindness I will never forget, and which spoke volumes and lifted my spirits in 1995 when I needed it during my ADN studies. BEDBUGS: INCREASING AWARENESS AND EDUCATING 3 Dedication My dear husband Jonathan, who has encouraged and supported me in all my crazy dreams. Without his help I would not have reached any of them, but with his support I feel I have touched the moon! My four wonderful children Ben, Michael, Anna, and Isaac, and their sweethearts who were each often heard cheering me on, saying “Good job!” and, “You can do it mom!”. My siblings Kay, Todd, LeAnn, Chad, Jill, Tracy, Amy, Ryan and their families who gave me constant encouragement and helped me to keep going when I didn’t think I could. My mom who ever encourages me and taught me to love learning. My new dad Enoch who is so kind. My late father who believed in me, whose gentle kindness, love, and quiet determination inspired me to dream big and to believe I can. BEDBUGS: INCREASING AWARENESS AND EDUCATING 4 Abstract Bedbugs have affected humans worldwide for more than four millennia. Bedbugs are spreading rapidly and becoming a financial, mental, and physical health problem. Many current providers are not familiar with the diagnosis, treatment, and education of patients about bedbug ailments. Homeless and low-income populations are at increased risk of infestations. The purpose of this project was to increase provider knowledge, awareness, and treatment of bedbugs at a community-based medical clinic. The Seager Memorial Clinic providers in Ogden, Utah, were given a pre-quiz (N=19) about best practices for bedbug ailments. An evidence-based educational video was then created, and providers watched and took a post quiz (N=16) using an open YouTube format. Survey results demonstrated an overall increase in mean provider knowledge scores from 45% to 84% after watching the video. Providers’ overall comfort level increased from 63.15% to 93.75%, and high comfort level from 5.23% to 37.5%. The video was also viewed by 111 additional participants from November 21st, 2020, to February 21st, 2021. Bedbugs continue to pose health risks for the homeless and low-income patients. Educating providers who care for these patients is critical in identifying and treating any associated issues. This Doctor of Nursing Practice project suggests that bedbug education can impact future practices and substantially improve patient care and outcomes. Keywords: bedbugs, evidence-based practice, homeless, low-income, bedbug ailments BEDBUGS: INCREASING AWARENESS AND EDUCATING 5 Bedbugs: Increasing Awareness and Educating Providers on Best Practices Cimex lectularius are also known as mahogany flats, chinches, red coats, and bedbugs (University of Florida, 2017). Bedbugs are increasingly common pests that live in areas where people sleep and cause irritating purpuric reactions in the humans they bite (Wang, Singh, Za, & Cooper, 2016). Bedbugs have become more prevalent globally and in the United States since the early 2000s (Wang, Singh, Za, & Cooper, 2016). Bedbugs are increasing rapidly in many states of the nation. In the state of Utah, there is a growing problem of bedbugs as reports rise for Utah homes, hotels, and apartment buildings (Utah Department of Health: Bureau of Epidemiology, 2020). Bedbugs are also affecting medical centers where they are said to be under-reported (Sheele, Barrett, Dash, & Ridge, 2017). Many people do not know the cause of their bedbug bites because the insects are nocturnal and expert hiders (Ibrahim, Syed, & Tomecki, 2017). Providers often mistake bedbug bites for other diagnoses, and as a result, patients do not receive correct care, experience reoccurrence of bedbug rashes, and suffer unnecessarily (Ibrahim, Syed, & Tomecki, 2017). Another consequence of misdiagnosing patients who have bedbugs is that the problem can go untreated and can worsen until it becomes challenging to manage and nearly impossible to eradicate (Wang, Singh, Za, & Cooper, 2016). According to research, bedbugs are an increasing problem in low-income communities (Wang, Singh, Za, & Cooper, 2016). Problem Statement BEDBUGS: INCREASING AWARENESS AND EDUCATING 6 According to Ibrahim, Syed, & Tomecki (2017), Bedbugs are increasing nationally in exponential numbers. Because of a scarcity of bedbugs during the 20th century, providers who were educated and practicing during that time, from the 1950s to the 2000s, have limited experience in diagnosing, treating, and patient teaching on bedbug issues (Wang, Singh, Za, & Cooper, 2016). Locally, homeless patients, as well as low-income individuals who receive free healthcare at the Seager Memorial Clinic in Ogden, Utah, are experiencing increasing numbers of bedbug rashes (Ruth Brockman, personal communication, December 16, 2019). Ruth Brockman RN, MBA, who directs the Seager Memorial Clinic, explains that many volunteer providers have not had prior experience in diagnosing, treating, and educating patients on bedbugs and may lack expertise in this area. She states that many volunteers, including providers, are asking for more information about bedbugs and the issues that accompany them. She agrees that providers can benefit from specific education on evidence-based bedbug care (Ruth Brockman, personal communication, April 8, 2020). Logically, patients with bedbugs who do not receive a proper diagnosis, will continue to suffer as the problem does not typically go away on its own and only gets worse without proper intervention (Wang, Singh, Za, & Cooper, 2016). Providers who do not identify bedbug rashes do not understand the problems that their patients with bedbugs will have and subsequently will not be able to find the correct solutions for them. Presently, not all patients receive proper treatment, nor do they receive effective patient education (Ibrahim, Syed, & Tomecki, 2017). Providers may become frustrated as their patients do not recover from incorrect or ineffective treatments. Overall numbers of bedbug infestations are at risk of continual increase (Wang, Singh, Za, & Cooper, 2016). A lack of action to address the problem among patients who seek help may contribute to a larger problem in the community, especially if patient bedbug problems are not identified by providers and halted early (Ibrahim, BEDBUGS: INCREASING AWARENESS AND EDUCATING 7 Syed, & Tomecki, 2017). With the current situation of bedbug resurgence, providers of patients who are at high risk of experiencing bedbugs need to become more aware of the problem. Providers need to be reminded of or educated on clinical symptoms, diagnostic criteria, treatments, and actions that can be taken by patients to treat and prevent further problems. Clinical Questions There are many critical questions that drive the inquiries of this project. Will an educational course about how to best care for and treat patients with bedbug ailments help to increase the knowledge of providers at Seager Memorial Clinic? Will such a course be easily distributed and or accepted by providers? Will a publicly posted educational video, a PowerPoint, and pre- and post quizzes be useful tools in educating providers as well as in raising awareness of the problem? Will a publicly posted video of the problem garner views? Will providers have an increase in confidence and comfort levels in diagnosing and treating patients with bedbug ailments after participation in such a course? Most importantly, will patients of the Seager Clinic receive faster diagnosis and better treatment of bedbug ailments because of the course? Improvement Plan for Provider Education The student proposed an educational course to close the gaps at the Seager Memorial Clinic by improving providers’ comfort, knowledge, and understanding of best practices for treating patients with bedbug ailments. The proposed plan was to develop an educational module with a pre-quiz to test provider knowledge. After the pre-quiz, an educational PowerPoint and video on an open YouTube format was to be given to the providers, followed by a post quiz to evaluate knowledge gained. It was proposed that the comparison of the pre- and post quizzes would determine both a level of comfort in treating and a measure of increased knowledge. The BEDBUGS: INCREASING AWARENESS AND EDUCATING 8 plan was to have a video and PowerPoint teach information on the history, appearance, and basics of bedbug problems as they affect patients, the identification of bedbug rashes, ailments, and infestations. The student also planned to teach how to deliver best practices once a patient is properly diagnosed and about patient resources and behaviors that patients can employ to help remedy and prevent the problem at home. It was proposed that if providers increased their knowledge and comfort levels, they would be more likely to give better levels of care with increased effectiveness and improved patient outcomes. Statement of Purpose, Aims, and Goals The purpose of this project was to increase provider awareness and provider knowledge of proper diagnosis, treatment, and patient teaching on bedbugs among the homeless and low-income populations as well as to increase awareness of bedbug ailments to the public, to community members and patients of the Seager Memorial Clinic. The specific aims were to create an educational module with a PowerPoint, video, pre- and post quizzes and to increase post quiz scores. This aim included a goal of teaching best practices for bedbug care. Another aim was to provide education and awareness to the providers and the public through the posting of an informational video. A final aim was to increase quality of care and treatment to homeless and low-income patients who are experiencing negative health effects from bedbug ailments. Review of Literature Define the Search An evaluation of available online information sources of evidence-based practice for bedbug treatment, control, and prevention was performed. This search was accomplished by examining professional health care literature using CINAHL, PubMed, PlosOne, Google Scholar, the Stewart Library One Search, and national and local government literature. Search BEDBUGS: INCREASING AWARENESS AND EDUCATING 9 terms used are bedbug history, bedbug and homeless, homelessness, lower-income communities, bedbug costs, bedbug best practices, bedbugs and evidence-based practice, bedbug treatments, bedbug scourge, homeless care avoidance, provider education methods, nurse practitioner numbers, physician numbers, provider education, best practices for patients with bedbug problems, guidelines for treating patients with bedbugs. Searches were for research that was done within the last five years. Cimexlectularius (Bedbugs) Bedbugs are small flat ectoparasitic insects that live in areas where humans live. They feed on humans while they sleep and usually hide nearby in small crevices. They are of the Cimex genus and Cimicidae family. There are three main types of bedbugs that attack humans. These are Cimex lectularius, common in the U.S., and Cimex hemipterus, a tropical bedbug (Criado, Junior, Jardim Criado, Silva, & Vasconcellos, 2011). The third bedbug is called leptocimex boueti, which is also called a bat bug and is found in Africa (Rosenfeld et al., 2016). According to Ibrahim et al., (2017), as adults, bedbugs are four to five millimeters in length. At that size, the adult bedbug is slightly larger than a flax seed (Ibrahim, Syed, & Tomecki, 2017). Bedbugs are a dark or reddish-brown color, are oval and exceptionally flat (Federal Trade Commission [FTC], 2012). Bedbugs hide and nest in small cracks and crevices of furniture, bed frames, bedding, and mattresses as well as in walls, dressers, carpets, floorboards, and baseboards (Federal Trade Commission [FTC], 2012). They change shape from flat to round and plump after feasting on the blood of their hosts, which is primarily humans (Rosenfeld et al., 2016). Though they can also feed on bats, mice, guinea pigs, dogs, and cats, among other animals (Rosenfeld et al., 2016). Bedbug History BEDBUGS: INCREASING AWARENESS AND EDUCATING 10 Historically, bedbugs have been cohabitating with and plaguing humans for thousands of years (Ibrahim, Syed, & Tomecki, 2017). During the last century, bedbug numbers dropped until they were rarely heard of or seen, but current numbers show an exponential increase and resurgence of bedbug sightings in the United States (Ibrahim, Syed, & Tomecki, 2017). Reports of bedbugs in the U.S. began in 1998 and are increasingly occurring in lower-income populations (Wang, Singh, Za, & Cooper, 2016). Bedbug bites can result in painful and intensely itchy macules, vesicles, and bullae (Ibrahim, Syed, & Tomecki, 2017). Bedbugs often cause loss of sleep as well as psychological distress (Wang, Singh, Za, & Cooper, 2016). Providers must identify bedbug bites in their patients quickly so that patients can receive proper treatment, experience relief, and be given effective patient teaching on how to stop and prevent the problem from reoccurring (Ibrahim, Syed, & Tomecki, 2017). It has been shown that providers often misdiagnose bedbug bites, confusing them with allergies, infections, and other insect bites such as scabies, flea bites, and mosquito bites, thus, delaying proper education and treatment (Ibrahim, Syed, & Tomecki, 2017). Patients who are homeless or who live in low-income housing have disproportionately higher rates of bedbugs than other communities (Wang, Singh, Za, & Cooper, 2016). Ideally, communities should include bedbugs when discussing public health (Schneider, 2019). Since providers are at the forefront of bedbug diagnosis, they need to be able to properly diagnose, treat, and teach patients about bedbugs, especially patients who are at increased risk of experiencing bedbugs and who have fewer resources available (Ibrahim, Syed, & Tomecki, 2017). Signs and Symptoms of Bedbug Bites Bedbugs feed on humans during the night, and due to the bedbug anesthetic saliva, they leave a rash that may not be noticed until one to three days after the initial bite (Centers for BEDBUGS: INCREASING AWARENESS AND EDUCATING 11 Disease Control and Prevention [CDC], 2017). When bedbug rashes appear, they are often found in a “breakfast, lunch, and dinner” pattern: in groups of three or four, spaced a few centimeters apart (Peres, Tacito Yugar, & Haddad, Jr., 2018). The bites frequently occur on patient arms, hands, neck, and face as well as other areas of skin that are exposed during sleep and cause painful itchiness for up to fourteen days (McNeil, Jarrett, & Shreve, 2017). According to McNeil et al. (2017), other symptoms include insomnia and mental distress. The maculopapular lesions caused by bedbugs typically measure between 2-5mm each and have a small central punctum that is hemorrhagic (McNeil, Jarrett, & Shreve, 2017). Another indication of bedbugs is an occurrence of papular urticaria or wheals that continue to occur and exist in differing stages of healing. These bites continue for months or longer, as long as the person is exposed to bedbugs in their home, hotel, or other sleeping environments where bedbugs reside. Bedbugs can be detected not only by physical exam, but it is also by inspection of the home and sleeping quarters (Utah Department of Health: Bureau of Epidemiology [UDHBE], 2020). According to Utah’s Bureau of Epidemiology, it is crucial to survey the areas where people sleep for telltale signs of bedbug infestations. These signs include small blood spots or small black excrement spots found on mattress crevices, in pillowcases, on sheets, blankets, outlets, along carpet edges, in corners of baseboards, as well as bedbug skins on bedding, floors or furniture (Utah Department of Health: Bureau of Epidemiology [UDHBE], 2020). Need for Provider Education As of 2010, statistics show that there were more than 624,000 practicing physicians in the United States (Agency for Healthcare Research and Quality [AHRQ], 2018). There are more than 155,000 physician assistants (National Commission on Certification of Physician Assistants [NCCPA], 2017), and over 290,000 practicing nurse practitioners (American Association of BEDBUGS: INCREASING AWARENESS AND EDUCATING 12 Nurse Practitioners [AANP], 2020). All providers need to be educated on early and accurate detection of bedbugs so that quick treatment can occur. Currently, some providers mistake bedbugs for prurigo, allergic reactions, staph infections, chicken pox, spider bites, mosquito bites, antibiotics reactions, food reactions, and scabies, therefore, need supplemental education on bedbugs (McNeil, Jarrett, & Shreve, 2017). Best Practices Best practices for a patient with bedbugs include early and correct diagnosis, treatment with a three-prong approach, and thorough patient teaching (McNeil, Jarrett, & Shreve, 2017). The best diagnosis comes from a physical exam, as well as, from patient reports of bedbug signs in the home environment (McNeil, Jarrett, & Shreve, 2017). Current guidelines for the treatment of bedbugs include a focus on the skin, on the home or sleeping environment, and finally on the mental health of the patient (McNeil, Jarrett, & Shreve, 2017). According to McNeil et al. (2017), treatment modalities of bedbug rashes include oral antihistamines and topical steroids, but further action needs to be taken towards eradication of the infestation. Patients need to be taught to vacuum all areas of their homes, including bed frames, mattresses, and furniture, and to place mattresses and box springs in bedbug-proof encasements (McNeil, Jarrett, & Shreve, 2017). Patients need to know that they can kill bedbugs by washing and drying their laundry in hot water over 120 degrees (McNeil, Jarrett, & Shreve, 2017). They must also dry their laundry on the hottest temperature that the clothing can withstand for at least 30-40 minutes (University of Minnesota [UM], 2020). Patients should be taught to clean up cluttered areas and to reduce the hiding areas for bedbugs (United States Environmental Protection Agency [EPA], 2018) as well as to apply an inexpensive but effective insecticide called diatomaceous earth (DE) around bed legs, along edges where the wall meets the floor, inside inner frames of box springs and couches, BEDBUGS: INCREASING AWARENESS AND EDUCATING 13 along carpet edges, or anywhere where bedbugs are sure to be exposed to the dust (Agnew & Romero, 2017). According to Agnew and Romero (2017), DE in high dose exposure causes a 100% mortality to bedbugs after nine to ten days. If patients to not receive teaching and follow steps to prevent bedbugs in their home environment, they will continue to be exposed and will continue to suffer the negative physical, psychological, and social ramifications. According to McNeil et al. (2017), the emotional effects of bedbugs must be addressed since bedbug ailments can cause myriads of physiological symptoms including stress, worry, isolation, sleep disturbance, fatigue, fear, exasperation, anxiety, and even agitation. More serious effects on the psyche can include aggression, delusions of crawling sensations, depression, mental trauma, paranoia, devastation, psychosis, PTSD, worsening of preexisting mental conditions, and even suicide ideation (McNeil, Jarrett, & Shreve, 2017). A diagnosis of a bedbug rash is no laughing matter and should be taken seriously. Bedbug infestations are serious enough that the ICD-10 code, B88.9, has been designated for use in patients who are experiencing bedbug bites and infestations (ICD10 Data, 2020). Impact of Proper Care and Identification of Bedbugs Bedbug infestations are one of the most difficult problems to control, and timely provider identification of bedbugs in patients can help them to combat the problem before it becomes unmanageable (Doggett, Dwyer, Penas, & Russell, 2012). If providers do not properly identify bedbug bites, the problems at homes and apartments will not be contained and are at risk of continually increasing and spreading to other family members, friends, neighbors, acquaintances, and other locations such as grocery stores, movie theatres, shopping centers, homeless shelters, five-star hotels, airplanes, hospitals, and clinics. Bedbugs are a community problem; if one neighbor has them and does not realize it and therefore does not treat them, then the rest of the BEDBUGS: INCREASING AWARENESS AND EDUCATING 14 neighborhood could soon have them as well. It is important not to ignore the bedbug problem in the United States today and even more important for providers to be educated and aware of bedbugs so that they can make a difference by diagnosing them quickly and by educating their patients on where to find resources on how to prevent them and treat them. Bedbugs are also known to cause financial burdens on the people who are affected. The longer bedbugs are allowed to live in a room without efforts to combat them, the longer it will take to eradicate them. Bedbug infestations can be costly to treat. It is common for facilities and individuals to have to pay for multiple treatments costing some as much as $55,000 in one year (Scarpino & Althouse, 2019). It does not make sense to allow patients to suffer from these debilitating symptoms without addressing the problem. Providers who are trained in bedbug identification, treatment, and resources will be most assuredly more prepared and more inclined to help their patients with correct bedbug treatments. It is important to note that homeless or low-income individuals may not be willing to return to the clinic for a repeat visit (Ennis & Pearson-Shaver, 2019). To make matters worse, it is not uncommon for homeless and low-income individuals to have difficulty trusting others, including healthcare workers (Klop, Evenblij, Gootjes, de Veer, & Onweteaka-Philipsen, 2018). Providers need to diagnose and treat bedbug infestations at the first patient visit for all patients but especially for the homeless and low-income populations. Current Solutions Presently there is a paucity of information for provider education regarding bedbugs. One article on bedbugs that teaches basic information for providers, written by nurse practitioners has been presented for C.E. credits (McNeil, Jarrett, & Shreve, 2017) however, no other doctor, BEDBUGS: INCREASING AWARENESS AND EDUCATING 15 nurse practitioner, or other provider training on bedbug identification, treatment, and prevention or patient teaching has been found. This demonstrates the need for provider teaching modules that can be accessed easily to enlighten providers of the basics needed to treat and teach their patients properly. A video presentation is an effective way to teach providers about evidence-based practice concerning bedbug rashes (Vadnjal, 2017). A teaching intervention that includes a video or PowerPoint with a pre- and post-test has also been shown effective (Cowdery, Powell, Fleming, & Brown, 2019). The providers at the Seager Memorial Clinic were given a pre- and post-test and either viewed a teaching module in the form of a PowerPoint or watched a video that includes the same PowerPoint. Both teaching methods will be offered to providers who are likely busy. They were able to watch the material at their own convenience from home and could access the teaching modules via email links. Seager Memorial Clinic Gap The Seager Memorial Clinic is a free clinic that sees homeless patients up to three times each week. The patients who come in for bedbug bites are often treated but then are bitten again and again. This is because of the continued bedbug problem where they sleep in a local homeless shelter, and other places in the community. The homeless shelter in Ogden, and other shelters like it, may have wooden beds in the sleeping areas. It is a known fact that bedbugs are attracted to wood and can hide in the small cracks of wood very easily. The rescue mission and clinic also have carpeted floors, which are an easy place for bedbugs to hide (Valverde, 2019). The patients need to have a provider that can teach them useful techniques. They must be given teaching and tools to protect themselves from the bedbugs, and a provider-patient relationship is an effective relationship to accomplish that goal. BEDBUGS: INCREASING AWARENESS AND EDUCATING 16 A systematic review showing the uses of telemedicine with homeless populations also shows that there is a low level of health literacy as well as a low level of intrinsic motivation, which may contribute to the acceptance of bedbugs as a part of life. The loss of belief that the problem can be overcome with the loss of a goal-oriented mindset is also a barrier to combatting the bedbug problem (Parker et al., 2018). The homeless and low-income are a vulnerable population and have higher rates of illnesses that are up to three times higher than their counterparts who live in houses (Gabrielian et al., 2013). Sharing educational tools with affected patients may offer them a viable option to attempt to solve the problem instead of surrendering to it and giving up. Providers need to be able to empower their patients who have bedbugs by teaching them how to care for and prevent future problems with bedbugs. They need increased knowledge of how bedbugs affect their patients. They also need to be able to identify the problem in their patients. Population, Setting, and Focus While the United States has approximately 29.2 physicians per 10,000 population, Utah has a lower rate of physicians with 23.1 per 10,000 (Public Health Indicator Based Information System [IBIS], 2015). The number of advanced practice nurses in Utah, including midwives, nurse specialists, and nurse anesthetists as of 2015 is 2,169. Nurse practitioners in Utah total 1,670 for the same year, 2015 (The Utah Medical Education Council, 2017). In all of Utah, there are about 70 free or affordable clinics (FreeClinics.com, 2020). At the time of this paper, there are about 30 volunteer providers who regularly serve the indigent, homeless, and working poor at the Seager Memorial Clinic (Ruth Brockman, personal communication, April 8, 2020). All thirty providers were invited to participate in the project. BEDBUGS: INCREASING AWARENESS AND EDUCATING 17 Weber County, where Ogden is located, has 4.3 primary care physicians and five nurse practitioners per 10,000. This compares to 5.7 primary care physicians per 10,000 for all of Utah, and 6.6 nurse practitioners per 10,000 (Rural Health Information Hub [RHIhub], 2017). Central Weber County has been identified as a low-income area by the Health Resources Services and Administration and benefits greatly from low- or no-income health clinics (Health Resource and Services Administration [HRSA], 2020). A focus of this clinical concern is the homeless population in Ogden, Utah, and the providers who treat them at the Seager Memorial Clinic. The homeless and low-income populations are one of the hardest hit by the bedbug problem and are at a disadvantage because of their poverty (Trajer, Hammer, & Szigeti, 2019). The Seager memorial Clinic has physicians of many different specialties who volunteer at the clinic, including internal medicine, pulmonology, rheumatology, family practice, and general surgery. The nurse practitioners that see patients are from many specialties such as dermatology, endocrinology, general practice, and other backgrounds. None of the providers receive pay for their time but are all volunteers. The providers see approximately ten to twenty patients daily, three times weekly, which adds to 30 to 60 patients per week. Due to the current global COVID- 19 pandemic, which is still affecting many lives, the providers were asked to participate in the project electronically. There are fewer patients seen during the pandemic as well. Normally, the patients seen at the clinic are those that cannot pay for healthcare. These include the homeless, residents of shelters, low-income persons, and working poor (Seager Memorial Clinic [SMC], n.d.). The Model for Improvement and PDSA cycle BEDBUGS: INCREASING AWARENESS AND EDUCATING 18 The evidence-based theory that has been chosen for the DNP project on bedbugs is called the Plan, Do, Study, Act (PDSA) cycle. The cycle was developed by an engineer named W. Edwards Deming in 1943. Deming originally used the PDSA process to help companies that made products for the war efforts during World War II (Best & Neuhauser, 2005). The PDSA cycle was applied to the student DNP project and began with the identification of a need. “Plan” or identification of a need, is defined as the stage where a change is identified by looking for needed improvements and choosing a plan. ‘Do” is the name of the second stage in which the newly created change is implemented. The “Study”, or third stage measures and analyzes outcomes from the project activities and finally, “act” is the name of the last of four stages in the PDSA cycle, which is defined as moving to action if the change is not bringing the expected results. It precipitates beginning the PSDA cycle again and moving towards a new “plan” (Best & Neuhauser, 2006). The PDSA cycle continues until the desired effect is achieved (Institute for Healthcare Improvement [IHI], 2020). The PDSA was a useful, effective model for this project. Project Implementation Working Towards Project Goals The student pursued the goals of increasing accurate bedbug diagnoses and a decreasing delay in care due to inaccurate diagnoses by educating providers about best practices. The student indirectly sought to help those who are often exposed to bedbugs by teaching the providers who care for them. The student worked to raise awareness of the problem to providers and the public by posting an educational video to YouTube. The student also worked to increase provider comfort in treating bedbug ailments. Adaptation and Limitations BEDBUGS: INCREASING AWARENESS AND EDUCATING 19 Limitations of the project include the closure of the Seager Memorial Clinic which occurred in March of 2020 and prevented the student from having in-person interaction with patients and providers. The clinic’s closure was mainly due to the COVID-19 pandemic but was ironically also influenced by a severe infestation of bedbugs in the rescue mission building where the Clinic resides. Without patient visits the providers could not practice the knowledge they had obtained from the DNP project’s educational course and patient care could not be evaluated. The student could not review patient charts as part of the project due to the unexpected constraints. The expected outcome focus was changed to adapt to the constraints caused by the COVID-19 pandemic during 2020 and by a bedbug infestation at the site. Both occurrences influenced the student project. The student changed plans and adapted by implementing the educational process through an online educational format only instead of in person training. There were not many free photos of bedbugs found online so the student took photos of the pests and the marks they leave at a local business that helps the homeless in Ogden, Utah. The local shelter is known to have a severe infestation. DNP Leader Role As a DNP nurse leader, the student identified a problem at the Seager Memorial Clinic and developed an educational module to address that problem. The module was created by finding and gathering current correct information on best practices for doctors and nurse practitioners to use while treating patients with bedbug ailments. The student studied and organized the current data into teaching materials which included a PowerPoint presentation with narration and a video on an open YouTube platform. After reliable sources of research and information were chosen the student gleaned pertinent information and reduced that information to the most important pearls for providers and used it to create a pre- and post, ten-question quiz BEDBUGS: INCREASING AWARENESS AND EDUCATING 20 using SurveyMonkey®. The student developed a process to distribute the teaching module to providers and found methods to communicate the process to all providers of the clinic by coordinating with the executive director, Ruth Brockman. The student continued to practice the role of a DNP nurse leader by directing the educational process and facilitating access to the materials and by ensuring that the links were functioning and that the materials were available. Timeline The student chose a direction for the project in Fall of 2019 and performed a thorough literature review during the spring of 2020. The student presented a proposal for the project to WSU IRB during the summer of 2020 and during the Fall of 2020 drafted a quiz , wrote a storyboard, and prepared visuals for the educational video. In November of 2020 the student sought and hired Attn Video employees Jonathan and Michael Wright to help with recording and editing of the video. The student implemented the project on Tuesday, November 17th, 2020 by uploading the first version of the video however the student did not distribute the video because it did not meet the student’s standards. The student worked on and polished the video then uploaded an improved educational video four days later on Saturday, November 21st, 2020. The student published a “before” quiz about bedbug care and sent it to Ruth Brockman of the Seager Memorial Clinic who then forwarded the quiz link and instructions to thirty providers of the clinic on November 17, 2020. There were no responses to the student’s email, so the student asked the community project consultant, Ruth Brockman, for assistance. Brockman sent out all the above again per the student’s request on Saturday, November 28, 2020 to remind providers to watch the educational video and take the second quiz and. The number of YouTube video views was tracked. Ethical Considerations and IRB BEDBUGS: INCREASING AWARENESS AND EDUCATING 21 The DNP student obtained a certificate of Collaborative Institutional Training Initiative (CITI) training on October 18, 2019 and received IRB approval on August 17th, of 2020. The DNP student followed the guidelines as well as the American Nursing Association (ANA) code of ethics and emphasized the importance of protecting rights of the patient and providing health and safety (Haddad & Geiber, 2018). Evaluation and Data Analysis SurveyMonkey® and YouTube® were used to collect data for the results of the project. A total of 19 out of 30 doctors and nurse practitioners from the Seager Memorial Clinic participated in taking a before quiz, and 16, or 84% of the first group took a second, post quiz. The post quiz was taken after the providers watched an educational video that teaches providers important information about treating patients with bedbug health issues. The providers from the Seager Memorial Clinic scored an average of 45% correct answers on the first quiz and increased scores by 39 points to an average of 84% correct answers after watching the video. YouTube analytics shows the video received 111 unique views in three months and captured the viewers’ attention best for the first 7:45 which represents the video’s main content. The video called “Bedbugs: Increasing Awareness and Educating Providers on Best Practices” can be found at the following web address: [https://youtu.be/fqwbcloss_y], or by this link for those reading a digital form of this paper: https://youtu.be/fqWBCloss_Y. The video can also be found by entering the words “DNP, bedbug” in the same google search. Methods and Tools to Evaluate Project SurveyMonkey® has built in analyzation tools that were used to evaluate the data from the two quizzes. The online quiz maker also makes graphs and other visual representations of important data. YouTube® was used to collect simple view data by visiting the video site. The BEDBUGS: INCREASING AWARENESS AND EDUCATING 22 student optimized the search engine Google by repeatedly finding the video by searching with the words, “DNP”, and “bedbugs” in the same search. Before and after survey quizzes were distributed via Surveymonkey®. A third survey by the student was published on February 8th, 2021 with three questions asking for improvements or feedback. Four responses were received showing 100% agreement that the educational course helped prepare them for treating patients with bedbug associated ailments. One qualitative feedback statement was recorded which said regarding the quizzes and video; “No suggestions, it was terrific and educational!”. The student’s educational video was published on November 21st, 2020 and received 111 unique views by February 21st, 2021 as recorded via YouTube analytics. As of the date of this printing, there were no viewer comments on the YouTube® video link and 243 unique views. Analyzed Data An increase in knowledge and understanding of bedbug ailment diagnoses, treatments and teaching by providers of Seager Memorial Clinic were measured for changes in posttest scores compared to pretest scores. Provider, patient, and community awareness of bedbug issues were increased through video presentation. The first and last quizzes contain the exact same questions. The first quiz was published on November 17th, 2020 and received 19 participants who completed ten questions. The anonymous providers from the Seager Memorial Clinic took the first quiz from its published date until November 20th, 2020. The lowest score was 20%, and the highest score was 80% with a median at 70%. The average score of the first quiz was 45%. The video and second quiz were published on November 21st, 2020 and the links to both were sent by text message to the providers by Ruth Brockman, the director of the Seager BEDBUGS: INCREASING AWARENESS AND EDUCATING 23 Memorial clinic several days later. The respondents included 16 providers who watched the video then took all ten questions which resulted in a low score of 50%, and a high score of %100 with a median of 85%. The average score for the second quiz was 84% as shown in the graph below: BEDBUGS: INCREASING AWARENESS AND EDUCATING 24 stop BEDBUGS: INCREASING AWARENESS AND EDUCATING 25 The first question rated provider comfort levels; “How comfortable do you feel in diagnosing, treating, and educating patients about bedbug bites and how to deal with the problem of infestations?”. Due to the nature of the question, all answers to this question were counted as correct, and no answers were wrong. One person, or 5.26% chose “very comfortable” on the first quiz. This compares to six people, or 37.5% who chose “very comfortable” on the second quiz after the educational module. This is a 613% increase in those who felt “very comfortable” in response to this question and shows that providers felt much more confident in treating patients with bedbug ailments as shown by the graph below: Questions numbered two through eight consistently showed an increase in provider scores after the educational intervention was complete. The scores for questions nine and ten however did not improve, and in some cases showed a decrease in scores. The improvement for each question is show in Appendix J. BEDBUGS: INCREASING AWARENESS AND EDUCATING 26 Discussion, Conclusions, and Recommendations Discussion It is interesting to note that of the providers who are treating patients at the Seager Memorial Clinic which is known by locals to have a high incidence of bedbug exposure and ailments, only one provider felt “very comfortable” in treating for them before the educational course. After the course, six times more providers felt “very comfortable”. The results of the educational video and quizzes show that the overall goal of educating providers for the Seager Memorial Clinic was realized. Eight out of ten questions showed an improvement in scores. With the total score increasing from 45% in the pre-quiz to 84% in the post quiz, an improvement of 87% shows that there was an increase in knowledge and understanding of bedbug information for providers. Clinical implications are that because the providers have an improved understanding and increased comfort levels of treating patients who are experiencing bedbug rashes, they will be able to provide better care more confidently for their patients. This improvement in care will help to ameliorate some of the troubles in the lives of those who are suffering from the negative financial, mental, and physical ailments of bedbug ailments. The homeless and low-income of Ogden, Utah are already suffering from the ill effect of poverty. Clinically, as this project has shared, it is of greatest importance to help alleviate the severe negative effects of bedbug ailments. Teaching providers who are at the forefront of the problem is a most efficient way to help them. The goal of increasing awareness was reached by involving 19 providers in the project as well as by publicly posting an educational video about bedbug ailments and best practices. The video helped to educate and make viewers more aware of how serious the problem is and of how difficult the mental and physical health impacts can be for patients. BEDBUGS: INCREASING AWARENESS AND EDUCATING 27 The video has 243 views as of April 20, 2021 with a potential of hundreds more as the student continues to keep the video posted to the public and increase views by optimizing for searches and distributing the link to other organizations including homeless shelter clinics in Utah and abroad to make providers aware of the tools, they can use to improve care of patients suffering with bedbug ailments. Recommendations Recommendations for future projects include shortening the length of the video so that those providers who are in a hurry can glean the important information quickly. The shorter video should have salient points shown together in the beginning of the video. This is an observation from the student as 19, or 58% of the 33 providers that were invited to participate joined the group. If the providers knew there was a shorter video, more may have been inclined to watch it and take the quizzes. Any future projects involving pre and post quizzes would benefit from having the quizzes, the PowerPoint, and the video offered to them in the same text message, or email on the same day instead of having a four day wait between starting module and finishing the video and final quiz. The project would also benefit from being distributed through other methods including through QR code on printed flyers, and via search terms to find the video. The search terms “DNP” and “bedbug” used together on a Google search engine under video searches will easily locate the video. A website could be created with links to all the above information. The student realizes that the scores of the second quiz may have been much higher if the providers had been able to do everything in one sitting. The providers in this project had up to one week go by before they had time to revisit the video and the second quiz. The video and second quiz were sent to the providers four days after the first quiz. This seems to be too long and BEDBUGS: INCREASING AWARENESS AND EDUCATING 28 counterproductive to learning as well as counterproductive to retaining the participation in the project. By the time the second quiz and the video were sent, it was nearing the Christmas season which meant busier times for all. Another recommendation is to send the project links by cell phone instead of by email. The emails were not answered but the cell phone messages were. The student postulates that the reason for this phenomenon is that cell phones are more convenient, and easily accessible by most providers in a current high technology environment. Email addresses may not have been current. Also, the scores of the last two quiz questions did not increase after education and should either be rewritten or more emphasis should be placed on these areas in the educational PowerPoint and video. Either way, the last two questions need to be addressed before future administrations of the course. A revision of sending the pre- and post- quiz links along with the educational video link all in the same text message should be done to increase the ease of taking the quizzes and to create a message that is complete with all the necessary information at one time and in one message. Conclusion Bedbug plagues are more common today than in previous decades and are a cause of great distress to humans. The suffering that comes from bedbug bites is a severe distress to homeless and low-income in Ogden, Utah and to communities at large. Bedbugs were largely unheard of for most of the last 60 years and providers have little experience treating them. Bedbugs are resurging at an astonishing rate and are found in all 50 states of the US. This problem needs to be addressed for the benefit of the homeless and low-income members of the population and all community members. Providers are in a key position to make a difference for patients with bedbug ailments. Physicians, physician assistants, and nurse practitioners need to BEDBUGS: INCREASING AWARENESS AND EDUCATING 29 be educated about the most current and best practices in treating patients’ bedbug bite symptoms and resources for treating the problem at home. Providers of the Seager Memorial Clinic for the homeless and low-income have an opportunity to recognize, diagnose and treat patients correctly to help stop the suffering from bedbug ailments when they occur and will be able to once the clinic reopens. Providers who are educated and have resources including video education and quizzes as well as an increased awareness are more apt to treat patients appropriately thus reducing incidents of delays in care. The DNP student’s project of educational quizzes and video instruction shows a large increase in knowledge after involvement. The homeless and low-income are already suffering and need the best help from their providers as is possible. This project increased knowledge for 16 providers and increased awareness of 111 YouTube viewers and benefits APRNs and physicians who treat those at high risk for bedbug ailments. This project will potentially benefit homeless and low-income patients. By helping the providers of the Seager Memorial Clinic of Ogden and their homeless and lower income patients, we are helping much more than just a small group of patients, but we are beginning a movement that has the potential to spread to a much bigger area and the greater good. 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Journal of Medical Entomology, 53(3), 639-646. http://dx.doi.org/ 10.1093/jme/tjw018 BEDBUGS: INCREASING AWARENESS AND EDUCATING 37 Appendix A BEDBUGS: INCREASING AWARENESS AND EDUCATING 38 Appendix B Acceptance letter from IRB chair Matthew Nicholaou on August 7, 2020 BEDBUGS: INCREASING AWARENESS AND EDUCATING 39 Appendix C Letter of Support BEDBUGS: INCREASING AWARENESS AND EDUCATING 40 Appendix D Pre- and Post-Quiz Score Data Pre & Post Quiz Percent Correct Pre- Quiz Percent Correct Post Quiz Average Score Pre- Quiz Average Score Post Quiz Standard Deviation Pre-Quiz Standard Deviation Post Quiz Difficulty Pre-Quiz Difficulty Post Quiz Question 1 100% 100% 1.0/1.0 1.0/1.0 0.00 0.00 10/10 9/10 Question 2 68% 94% 0.7/1.0 0.9/1.0 0.48 0.25 8/10 6/10 Question 3 32% 94% 0.3/1.0 0.9/1.0 0.48 0.25 5/10 6/10 Question 4 16% 81% 0.2/1.0 0.8/1.0 0.37 0.40 2/10 3/10 Question 5 11% 94% 0.1/1.0 0.9/1.0 0.32 0.25 1/10** 6/10 Question 6 47% 100% 0.5/1.0 1.0/1.0 0.51 0.00 6/10 9/10 Question 7 16% 63% 0.2/1.0 0.6/1.0 0.37 0.50 2/10 2/10 Question 8 16% 88% 0.2/1.0 0.9/1.0 0.37 0.34 2/10 4/10 Question 9 53% 44%* 0.5/1.0 0.4/1.0 0.51 0.51 7/10 1/10** Question 10 89% 88%* 0.9/1.0 0.9/1.0 0.32 0.34 9/10 4/10 *yellow shows decrease in post-video quiz scores **gray shows most difficult quiz questions BEDBUGS: INCREASING AWARENESS AND EDUCATING 41 Appendix E Pre- Education Quiz Questions Difficulty Ranking and Average Score on Survey Monkey® BEDBUGS: INCREASING AWARENESS AND EDUCATING 42 Appendix F Overall difference between pre-education quiz scores and post-education quiz scores: BEDBUGS: INCREASING AWARENESS AND EDUCATING 43 Appendix G BEDBUGS: INCREASING AWARENESS AND EDUCATING 44 Appendix H Pre-Education Quiz Summary of 19 Providers using Survey Monkey® BEDBUGS: INCREASING AWARENESS AND EDUCATING 45 Appendix I Post Education Quiz Summary of 16 Providers using Survey Monkey® BEDBUGS: INCREASING AWARENESS AND EDUCATING 46 Appendix J BEDBUGS: INCREASING AWARENESS AND EDUCATING 47 Appendix K Video’s Thumbprint on Student’s YouTube Channel as of 2/21/2021 BEDBUGS: INCREASING AWARENESS AND EDUCATING 48 Appendix L Number of Video Views as of 11/28/2020 BEDBUGS: INCREASING AWARENESS AND EDUCATING 49 Appendix M Theoretical Framework BEDBUGS: INCREASING AWARENESS AND EDUCATING 50 Appendix N QR code to access educational video: BEDBUGS: INCREASING AWARENESS AND EDUCATING 51 Appendix O BEDBUGS: INCREASING AWARENESS AND EDUCATING 52 Appendix P Educational PowerPoint for Providers BEDBUGS: INCREASING AWARENESS AND EDUCATING 53 BEDBUGS: INCREASING AWARENESS AND EDUCATING 54 BEDBUGS: INCREASING AWARENESS AND EDUCATING 55 BEDBUGS: INCREASING AWARENESS AND EDUCATING 56 BEDBUGS: INCREASING AWARENESS AND EDUCATING 57 BEDBUGS: INCREASING AWARENESS AND EDUCATING 58 BEDBUGS: INCREASING AWARENESS AND EDUCATING 59 BEDBUGS: INCREASING AWARENESS AND EDUCATING 60 BEDBUGS: INCREASING AWARENESS AND EDUCATING 61 BEDBUGS: INCREASING AWARENESS AND EDUCATING 62 BEDBUGS: INCREASING AWARENESS AND EDUCATING 63 BEDBUGS: INCREASING AWARENESS AND EDUCATING 64 BEDBUGS: INCREASING AWARENESS AND EDUCATING 65 BEDBUGS: INCREASING AWARENESS AND EDUCATING 66 BEDBUGS: INCREASING AWARENESS AND EDUCATING 67 BEDBUGS: INCREASING AWARENESS AND EDUCATING 68 BEDBUGS: INCREASING AWARENESS AND EDUCATING 69 BEDBUGS: INCREASING AWARENESS AND EDUCATING 70 BEDBUGS: INCREASING AWARENESS AND EDUCATING 71 BEDBUGS: INCREASING AWARENESS AND EDUCATING 72 Appendix Q Formal Oral Presentation BEDBUGS: INCREASING AWARENESS AND EDUCATING 73 BEDBUGS: INCREASING AWARENESS AND EDUCATING 74 BEDBUGS: INCREASING AWARENESS AND EDUCATING 75 BEDBUGS: INCREASING AWARENESS AND EDUCATING 76 BEDBUGS: INCREASING AWARENESS AND EDUCATING 77 BEDBUGS: INCREASING AWARENESS AND EDUCATING 78 BEDBUGS: INCREASING AWARENESS AND EDUCATING 79 BEDBUGS: INCREASING AWARENESS AND EDUCATING 80 BEDBUGS: INCREASING AWARENESS AND EDUCATING 81 BEDBUGS: INCREASING AWARENESS AND EDUCATING 82 BEDBUGS: INCREASING AWARENESS AND EDUCATING 83 Appendix R Questions Providers Can Ask Patients to Help Identify Bedbugs Have you traveled recently? Have you moved to a new apartment or home? Have you slept in a home or hotel that is known to have bedbugs? Do you see any small black “ink” spots, or small blood spots on your bedding? Each morning, do you wake up with new rash areas or red, raised spots? Do you continue to get new red raised rash spots even if you sleep somewhere other than your usual sleeping area? Do the “bites” or rash areas itch intensely? Do the “bites” or rash areas hurt, or burn? Do the “bites” appear in a line? Are the red rash bumps sometimes in a group of three or four? Does anyone else in the area where you live have a similar rash? Do you know that not all people react to bedbug bites? How long does each red, raised spot last until it goes away? Have you or anyone near you in your living quarters recently obtained used furniture? Did you inspect the furniture for bedbugs after you brought it to your place of residence? Have you checked cracks and crevices of your room for bedbugs? Have you seen any bedbugs near your sleeping area? Do you know what a bed bug looks like? – Here is a picture If homeless, have you stayed in a shelter that is known to have bedbugs? Do you live in an area where different people come and go each night? Have you turned on the lights in the early morning hours before dawn to see if there are any bedbugs near you? Do you have insomnia? Are the bites on areas of your skin that are exposed while you are sleeping? such as on the face, neck, arms, and or legs? If you have bites on your legs, do others who ride a train, or bus with you also get these bites? For a synapse of the current Bedbug problem see NRSG7030SignatureAssignemment at hmw801 portfolium https://portfolium.com/entry/nrsg-7030-information-technology-to-support-ebp